Measurement protocols and determinants of peak oxygen consumption in adults with Down syndrome: a systematic review

This systematic review aimed to provide an overview of test protocols used to measure peak oxygen uptake (VO2peak) in adults with Down syndrome (DS) and to determine how generalisable the outcomes are for the entire population of adults with DS by describing the sample characteristics of these studies and their impact on VO2peak. A literature search (PROSPERO CRD42022309560) was performed (18 July 2023) using the following databases: PubMed, CINAHL, APA PsycINFO, Web of Science, Embase and SPORTDiscus. For articles to be included, they had to be peer-reviewed pubications, reporting VO2peak or VO2max for individuals with DS separately, with a sample of n ≥ 5 and a mean age ≥18 years. Systematic reviews and meta-analyses were excluded but their reference lists were searched for additional papers to include. Studies were evaluated for risk of bias following the guidelines of Kmet et al. The results were summarised with frequency statistics. Forty-three studies were included in this systematic review. Sample sizes of included adults with DS ranged from n = 4-226, with a total of n = 1498 adults with DS being included. Most studies (29/43) used the same standardised maximal exercise treadmill protocol to measure VO2peak in adults with DS, and 33 out of 43 studies used at least one objective criterion to determine a valid maximal effort. Participants were predominantly male, under 40 years old, and overweight or obese. Additionally, the diversity of study samples was lacking or not reported. The most widely used, standardised, maximal exercise test treadmill protocol is recommended for future use in research and practice, including objective criteria to determine valid maximal effort. The current study samples are not representative of the population of adults with DS in terms of sex, age and diverse backgrounds and therefore likely overestimate VO2peak of this population.

The benefits of index telephone consultations in patients referred on the two-week wait colorectal cancer pathway

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic led to hospitals in the UK substituting face-to-face (FtF) clinics with virtual clinic (VC) appointments. We evaluated the use of virtual two-week wait (2-ww) lower gastrointestinal (LGI) clinic appointments, conducted using telephone calls at a district general hospital in England.

METHODS

Patients undergoing index outpatient 2-ww LGI clinic assessment between 1 June 2019 and 31 October 2019 (FtF group) and 1 June 2020 and 31 October 2020 (VC group) were identified. Relevant data were obtained using electronic patient records. Compliance with national cancer waiting time targets was assessed. Environmental and financial impact analyses were performed.

RESULTS

In total, 1,531 patients were analysed (median age=70, male=852, 55.6%). Of these, 757 (49.4%) were assessed virtually via telephone; the remainder were seen FtF (n=774, 50.6%). Ninety-two (6%, VC=44, FtF=48) patients had malignant pathology and 64 (4.2%) had colorectal cancer (CRC); of these, 46 (71.9%, VC=26, FtF=20) underwent treatment with curative intent. The median waiting times to index appointment, investigation and diagnosis were significantly lower following VC assessment (p<0.001). The cancer detection rates (p=0.749), treatments received (p=0.785) and median time to index treatment for CRC patients (p=0.156) were similar. A significantly higher proportion of patients were seen within two weeks of referral in the VC group (p<0.001). VC appointments saved patients a total of 9,288 miles, 0.7 metric tonnes of CO2 emissions and £7,482.97. Taxpayers saved £80,242.00 from VCs. No formal complaints were received from patients or staff in the VC group.

CONCLUSION

Virtual 2-ww LGI clinics were effective, safe and were associated with tangible environmental and financial benefits.

Evaluating the measures in patient-reported outcomes, values and experiences (EMPROVE study): a collaborative audit of PROMs practice in orthopaedic care in the United Kingdom

INTRODUCTION

All national orthopaedic societies advocate the use of patient reported outcome measures (PROMs), but clear guidance on their use is limited. We utilised a collaborative methodology to perform a national audit aiming to assess the perceived variability in PROMs practice in orthopaedic surgery in the United Kingdom.

METHODS

A multicentre collaborative audit of practice was performed extracting PROMs data on 21 commonly performed orthopaedic procedures. For each procedure, data were collected for frequency of PROM collection, type of PROM chosen, administration intervals, method and reason for collection. Compliance with national society recommendations was undertaken.

RESULTS

Sixty-three trusts enrolled to participate in the study with a completion rate of 60% (38 trusts). The most frequently reported PROMs were those associated with best practice tariffs (83.3% and 80.6% for hip and knee replacements, respectively). Outside incentivised programmes we observed a higher rate of variation in PROMs practice which failed to meet our audit standard. Across all procedures evaluated, 69% (221/318) of respondents to the study used paper as the primary method of PROM collection.

CONCLUSIONS

This is the first national audit of PROMs collection in orthopaedics. The integration of PROMs within best practice tariff platforms positively influences the frequency and standardisation of collection. Outside this initiative, PROMS collection is infrequent and highly varied despite the presence of several registries. Because PROMs collection is a recommendation across all procedures using implantable devices, the success of this will depend on the adequacy of funding, resource delivery and the presence of clearer recommendations.

Performance and health of broiler chickens fed low erucic acid, lower fiber pennycress (CoverCressTM) grain

CoverCress (low erucic acid, lower fiber pennycress) is being developed as a cover crop to be planted in the fall after corn and harvested in the spring prior to planting soybeans. Two experiments were conducted to evaluate 2 lines of the whole grain (CCWG-1: natural mutation and mutation breeding; CCWG-2: gene edited) and the whole grain pretreated with the potential palatability agent copper sulfate (CCWG-1-CuSO₄; CCWG-2-CuSO₄) as an ingredient for broilers. In Experiment 1, CCWG-1-CuSO₄ was included in the diet at 0, 4, and 6% for 41 d. Feed intake, body weight gain, feed conversion, processing characteristics, organ weights, serum thyroid, macropathology and histology data were collected. In Experiment 2, broilers were fed diets containing Control, 2% CCWG-1, 4% CCWG-1, 4% CCWG-2, and 4.35% CCWG-1-CuSO₄ for 42 d. Feed intake, body weight gain, feed conversion, organ weights, serum thyroid, blood chemistries, macropathology, and histology data were collected. In Experiment 1, feed intake and body weight were diminished with no effect on feed conversion for the birds consuming diets containing CCWG-1-CuSO₄. In Experiment 2, feed intake and body weight were lower with no difference in feed conversion in birds fed diets containing greater than 2% CoverCress grain during d 0 to 28. During d 28 to 42 no difference in feed intake, body weight and an improvement in feed conversion was observed in birds fed all of the CoverCress grain products. In both experiments no significant negative effects were observed in processing, liver, kidney, and thyroid weights, T3, T4, blood chemistries, macropathology, and histopathology between the control and any of the CoverCress grain treatments. No difference in performance was observed in birds fed the mutant (4% CCWG-1) and gene-edited (4% CCWG-2) products. Pretreating CoverCress grain with copper sulfate did not have a significant effect on improving palatability. In conclusion, CoverCress grain can be safely fed to broilers when included at a target rate of 4% in diets and with total glucosinolate levels not to exceed 4.9 µmoles g^-1.

Tolerability of graded levels of tall oil fatty acids as a nutritional additive for broiler chickens: a 45-day target animal safety study

1. The following study was conducted to evaluate the tolerability of tall oil fatty acid (TOFA) to broiler chickens, at 3 graded levels as a nutritional additive in complete feed.2. 256 one-day-old female and male Cobb 500 broiler chickens were assigned to four dietary treatment groups with TOFA at 0 (control), 1.0, 3.0, or 5.0 g/kg complete feed for 45 days.3. Birds were weighed individually on days 0, 16, 31, and 45, and the feed intake, bird weight gain, and feed conversion ratio were calculated for the respective starter, grower and finisher phases and over the whole study. On day 45, blood samples were drawn from each bird for haematology and blood chemistry measurements. Two birds per pen were subjected to gross pathological examination and sampling of several tissues for histopathology, including weighing the liver.4. The dietary treatments did not affect zootechnical performance parameters or mortality over the whole study period. Bird performance was typical for the breed.5. Haematology, clinical chemistry and histopathology did not reveal any changes associated with dietary TOFA dosing. However, the 5.0 g/kg dose level increased the relative weight of the liver, as a percentage of final body weight, compared to the control group, but there was lack of corresponding histopathology findings.6. In conclusion, the study indicated that oral administration of TOFA for 45 days in feed was well tolerated by the birds at dietary levels of up to 5.0 g/kg.

Overexpression of UDP-glucuronosyltransferase and cytochrome P450 enzymes confers resistance to sulfoxaflor in field populations of the aphid, Myzus persicae

The green peach aphid, Myzus persicae, is a highly damaging, globally distributed crop pest that has evolved multiple resistance to numerous insecticides. It is thus imperative that insecticides that are not strongly compromised by pre-existing resistance are carefully managed to maximise their effective life span. Sulfoxaflor is a sulfoximine insecticide that retains efficacy against M. persicae clones that exhibit resistance to older insecticides. In the current study we monitored the efficacy of sulfoxaflor against M. persicae populations collected in Western Australia, following reports of control failures in this region. We identified clones with low (4-23-fold across multiple independent bioassay experiments), but significant, levels of resistance to sulfoxaflor compared with a reference susceptible clone. Furthermore, we demonstrate that sulfoxaflor resistance can persist after many months of culturing in the laboratory in the absence of insecticide exposure. Resistance was not conferred by known mechanisms of resistance to neonicotinoid insecticides, that act on the same target-site as sulfoxaflor, i.e. the R81T mutation or overexpresssion of the P450 gene CYP6CY3. Rather, transcriptome profiling of multiple resistant and susceptible clones identified the P450 CYP380C40 and the UDP-glucuronosyltransferase UGT344P2 as highly overexpressed (21-76-fold and 6-33-fold respectively) in the resistant clones. Transgenic expression of these genes demonstrated that they confer, low, but significant, levels of resistance to sulfoxaflor in vivo. Taken together, our data reveal the presence of low-level resistance to sulfoxaflor in M. persicae populations in Australia and uncover two novel mechanisms conferring resistance to this compound. The findings and tools generated in this study provide a platform for the development of strategies that aim to slow, prevent or overcome the evolution of more potent resistance to sulfoxaflor.

Function is a better predictor of plant rhizosphere community membership than 16S phylogeny

Rhizobacterial communities are important for plant health but we still have limited understanding of how they are constructed or how they can be manipulated. High-throughput 16S rRNA sequencing provides good information on taxonomic composition but remains an unreliable proxy for phenotypes. In this study, we tested the hypothesis that experimentally observed functional traits would be better predictors of community membership than phylogenetic origin. To test this hypothesis, we sampled communities on four plant species grown in two soil types and characterized 593 bacterial isolates in terms of antibiotic susceptibility, carbon metabolism, resource use and plant growth-promoting traits. In support of our hypothesis we found that three of the four plant species had phylogenetically diverse, but functionally constrained communities. Notably, communities did not grow best on complex media mimicking their host of origin but were distinguished by variation in overall growth characteristics (copiotrophy/oligotrophy) and antibiotic susceptibility. These data, combined with variation in phylogenetic structure, suggest that different classes of traits (antagonistic competition or resource-based) are more important in different communities. This culture-based approach supports and complements the findings of a previous high-throughput 16S rRNA analysis of this experiment and provides functional insights into the patterns observed with culture-independent methods.

Mistaken Identity: Frequency and Effects of Gender-Based Professional Misidentification of Resident Physicians

PURPOSE

Evaluation of the medical profession at all levels has exposed episodes of gender-based role misidentification whereby women physicians are disproportionately misidentified as nonphysicians. The authors of this study investigate this phenomenon and its repercussions, quantifying the frequency with which resident physicians experience role misidentification and the effect this has on their experience and behavior.

METHOD

In 2018, the authors conducted a cross-sectional survey study of internal medicine, surgical, and emergency medicine residents at a single, large, urban, tertiary academic medical center. The survey tool captured both the self-reported frequency and effect of professional misidentification. The authors used a t test and linear multivariate regression to analyze the results.

RESULTS

Of the 260 residents who received the survey, 186 (72%) responded, and the authors analyzed the responses of 182. All 85 of the women respondents (100%) reported being misidentified as nonphysicians at least once in their professional experience by patients or staff members, compared with 49% of the 97 men respondents. Of those 182 residents, 35% of women were misidentified more than 8 times per month by patients compared with 1% of men. Of the 85 women physicians responding to the survey, 38% felt angry and 36% felt less satisfied with their jobs as a result of misidentification compared with, respectively, 7% and 9% of men. In response to role misidentification, 51% of women changed their manner of attire and 81% changed their manner of introduction, compared with, respectively, 7% and 37% of men.

CONCLUSIONS

These survey results demonstrate that women physicians are more likely than men physicians to be misidentified as nonphysicians and that role misidentification provokes gender-polarized psychological and behavioral responses that have potentially important professional ramifications.

Bleeding risk by intensity of anticoagulation in critically ill patients with COVID-19: A retrospective cohort study

BACKGROUND

Studies report hypercoagulability in coronavirus disease 2019 (COVID-19), leading many institutions to escalate anticoagulation intensity for thrombosis prophylaxis.

OBJECTIVE

To determine the bleeding risk with various intensities of anticoagulation in critically ill patients with COVID-19 compared with other respiratory viral illnesses (ORVI).

PATIENTS/METHODS

This retrospective cohort study compared the incidence of major bleeding in patients admitted to an intensive care unit (ICU) within a single health system with COVID-19 versus ORVI. In the COVID-19 cohort, we assessed the effect of anticoagulation intensity received on ICU admission on bleeding risk. We performed a secondary analysis with anticoagulation intensity as a time-varying covariate to reflect dose changes after ICU admission.

RESULTS

Four hundred and forty-three and 387 patients were included in the COVID-19 and ORVI cohorts, respectively. The hazard ratio of major bleeding for the COVID-19 cohort relative to the ORVI cohort was 1.26 (95% confidence interval [CI]: 0.86-1.86). In COVID-19 patients, an inverse-probability treatment weighted model found therapeutic-intensity anticoagulation on ICU admission had an adjusted hazard ratio of bleeding of 1.55 (95% CI: 0.88-2.73) compared with standard prophylactic-intensity anticoagulation. However, when anticoagulation was assessed as a time-varying covariate and adjusted for other risk factors for bleeding, the adjusted hazard ratio for bleeding on therapeutic-intensity anticoagulation compared with standard thromboprophylaxis was 2.59 (95% CI: 1.20-5.57).

CONCLUSIONS

Critically ill patients with COVID-19 had a similar bleeding risk as ORVI patients. When accounting for changes in anticoagulation that occurred in COVID-19 patients, therapeutic-intensity anticoagulation was associated with a greater risk of major bleeding compared with standard thromboprophylaxis.

Color recognition of design object of manual decoration element based on convolution neural network under the impact of COVID-19

The popularity of covid-19 has led to the introduction of the policy of controlling the flow of personnel, which has a certain impact on the color recognition of the design objects of hand decorative elements. In the past, the research on convolution neural network design and color recognition is still in the traditional method, and the field of computer vision is not really combined with the traditional decorative fabric. This paper proposes a solution based on deep learning. Color learning and main color recognition can be processed as a whole. By introducing convolution neural network, the scheme can learn color features directly from the image itself, and the process of artificial design features is omitted. While simplifying the process of model building and training, the potential information association can be obtained, so as to obtain better recognition effect. In addition, due to the deep depth of the network, this paper uses the initial optimization module to avoid the performance degradation and over fitting in the training process. This method has an important reference value for the color design of modern hand decoration, and can promote the development of hand decoration during the popularity of covid-19.

COVID-19: The need for an Australian economic pandemic response plan

OBJECTIVES

Pandemics pressure national governments to respond swiftly. Mitigation efforts created an imbalance between population health, capacity of the healthcare system and economic prosperity. Each pandemic arising from a new virus is unknown territory for policy makers, and there is considerable uncertainty of the appropriateness of responses and outcomes.

METHODS

A qualitative approach was used to review mixed sources of data including Australian reports, official government publications, and COVID-19 data to discern robust future responses. Publicly available epidemiological and economic data were utilised to provide insight into the impact of the pandemic on Australia's healthcare system and economy.

RESULTS

Policies implemented by the Australian Government to mitigate the spread of COVID-19 impacted the healthcare sector and economy. This paper incorporates lessons learned to inform optimal economic preparedness. The rationale for an economic response plan concomitant with the health pandemic plan is explored to guide Australian Government policy makers in ensuring holistic and robust solutions for future pandemics.

CONCLUSIONS

In future, an Australian Economic Pandemic Response Plan will aid in health and economic system preparedness, whilst a strong Australian economy and strategic planning will ensure resilience to future pandemics.

Receiving Real-Time Clinical Feedback: A Workshop and OSTE Assessment for Medical Students

BACKGROUND

Many programs designed to improve feedback to students focus on faculty's ability to provide a safe learning environment, and specific, actionable suggestions for improvement. Little attention has been paid to improving students' attitudes and skills in accepting and responding to feedback effectively. Effective "real-time" feedback in the clinical setting is dependent on both the skill of the teacher and the learner's ability to receive the feedback. Medical students entering their clinical clerkships are not formally trained in receiving feedback, despite the significant amount of feedback received during this time.

METHODS

We developed and implemented a one-hour workshop to teach medical students strategies for effectively receiving and responding to "real-time" (formative) feedback in the clinical environment. Subjective confidence and skill in receiving real-time feedback were assessed in pre- and post-workshop surveys. Objective performance of receiving feedback was evaluated before and after the workshop using a simulated feedback encounter designed to re-create common clinical and cognitive pitfalls for medical students, called an objective structured teaching exercise (OSTE).

RESULTS

After a single workshop, students self-reported increased confidence (mean 6.0 to 7.4 out of 10, P<0.01) and skill (mean 6.0 to 7.0 out of 10, P=0.10). Compared to pre-workshop OSTE scores, post-workshop OSTE scores objectively measuring skill in receiving feedback were also significantly higher (mean 28.8 to 34.5 out of 40, P=0.0131).

CONCLUSION

A one-hour workshop dedicated to strategies in receiving real-time feedback may improve effective feedback reception as well as self-perceived skill and confidence in receiving feedback. Providing strategies to trainees to improve their ability to effectively receive feedback may be a high-yield approach to both strengthen the power of feedback in the clinical environment and enrich the clinical experience of the medical student.

'Everything was just getting worse and worse': deteriorating job quality as a driver of doctor emigration from Ireland

BACKGROUND

Medicine is a high-status, high-skill occupation which has traditionally provided access to good quality jobs and relatively high salaries. In Ireland, historic underfunding combined with austerity-related cutbacks has negatively impacted job quality to the extent that hospital medical jobs have begun to resemble extreme jobs. Extreme jobs combine components of a good quality job-high pay, high job control, challenging demands, with those of a low-quality job-long working hours, heavy workloads. Deteriorating job quality and the normalisation of extreme working is driving doctor emigration from Ireland and deterring return.

METHODS

Semi-structured qualitative interviews were conducted with 40 Irish emigrant doctors in Australia who had emigrated from Ireland since 2008. Interviews were held in July-August 2018.

RESULTS

Respondents reflected on their experiences of working in the Irish health system, describing hospital workplaces that were understaffed, overstretched and within which extreme working had become normalised, particularly in relation to long working hours, fast working pace, doing more with less and fighting a climate of negativity. Drawing on Hirschman's work on exit, voice and loyalty (1970), the authors consider doctor emigration as exit and present respondent experiences of voice prior to emigration. Only 14/40 respondent emigrant doctors intend to return to work in Ireland.

DISCUSSION

The deterioration in medical job quality and the normalisation of extreme working is a key driver of doctor emigration from Ireland, and deterring return. Irish trained hospital doctors emigrate to access good quality jobs in Australia and are increasingly likely to remain abroad once they have secured them. To improve doctor retention, health systems and employers must mitigate a gainst the emergence of extreme work in healthcare. Employee voice (about working conditions, about patient safety, etc.) should be encouraged and used to inform health system improvement and to mitigate exit.

Accuracy checking of dispensed medications by a pharmacy technician: a hospital case study

Medication order accuracy checking is an integral and time-consuming component of the current Australian pharmacist's role. However, the pharmacy profession internationally has moved towards separating the checking task into two parts: a clinical check performed by the registered pharmacist and a technical accuracy check delegated to an appropriately trained pharmacy technician. This case study demonstrates that in an Australian hospital pharmacy context, appropriately trained pharmacy technicians have the potential to be more proficient and time efficient than pharmacists when undertaking accuracy checking of dispensed medications.

Targeted inhibition of CD47-SIRPα requires Fc-FcγR interactions to maximize activity in T-cell lymphomas

Antibodies that bind CD47 on tumor cells and prevent interaction with SIRPα on phagocytes are active against multiple cancer types including T-cell lymphoma (TCL). Here we demonstrate that surface CD47 is heterogeneously expressed across primary TCLs, whereas major histocompatibility complex (MHC) class I, which can also suppress phagocytosis, is ubiquitous. Multiple monoclonal antibodies (mAbs) that block CD47-SIRPα interaction promoted phagocytosis of TCL cells, which was enhanced by cotreatment with antibodies targeting MHC class I. Expression levels of surface CD47 and genes that modulate CD47 pyroglutamation did not correlate with the extent of phagocytosis induced by CD47 blockade in TCL lines. In vivo treatment of multiple human TCL patient-derived xenografts or an immunocompetent murine TCL model with a short course of anti-CD47 mAb markedly reduced lymphoma burden and extended survival. Depletion of macrophages reduced efficacy in vivo, whereas depletion of neutrophils had no effect. F(ab')2-only fragments of anti-CD47 antibodies failed to induce phagocytosis by human macrophages, indicating a requirement for Fc-Fcγ receptor interactions. In contrast, F(ab')2-only fragments increased phagocytosis by murine macrophages independent of SLAMF7-Mac-1 interaction. Full-length anti-CD47 mAbs also induced phagocytosis by Fcγ receptor-deficient murine macrophages. An immunoglobulin G1 anti-CD47 mAb induced phagocytosis and natural killer cell-mediated cytotoxicity of TCL cells that was augmented by cotreatment with mogamulizumab, an anti-CCR4 mAb, or a mAb blocking MHC class I. These studies help explain the disparate activity of monotherapy with agents that block CD47 in murine models compared with patients. They also have direct translational implications for the deployment of anti-CD47 mAbs alone or in combination.

Rhizobacterial Community Assembly Patterns Vary Between Crop Species

Currently our limited understanding of crop rhizosphere community assembly hinders attempts to manipulate it beneficially. Variation in root communities has been attributed to plant host effects, soil type, and plant condition, but it is hard to disentangle the relative importance of soil and host without experimental manipulation. To examine the effects of soil origin and host plant on root associated bacterial communities we experimentally manipulated four crop species in split-plot mesocosms and surveyed variation in bacterial diversity by Illumina amplicon sequencing. Overall, plant species had a greater impact than soil type on community composition. While plant species associated with different Operational Taxonomic Units (OTUs) in different soils, plants tended to recruit bacteria from similar, higher order, taxonomic groups in different soils. However, the effect of soil on root-associated communities varied between crop species: Onion had a relatively invariant bacterial community while other species (maize and pea) had a more variable community structure. Dynamic communities could result from environment specific recruitment, differential bacterial colonization or reflect broader symbiont host range; while invariant community assembly implies tighter evolutionary or ecological interactions between plants and root-associated bacteria. Irrespective of mechanism, it appears both communities and community assembly rules vary between crop species.

Cognitive, physical, and mental health outcomes between long-term cannabis and tobacco users

INTRODUCTION

Cannabis intoxication adversely affects health, yet persistent effects following short-term abstinence in long-term cannabis users are unclear. This matched-subjects, cross-sectional study compared health outcomes of long-term cannabis and long-term tobacco-only users, relative to population norms.

METHODS

Nineteen long-term (mean 32.3years of use, mean age 55.7years), abstinent (mean 15h) cannabis users and 16 long-term tobacco users (mean 37.1years of use, mean age 52.9years), matched for age, educational attainment, and lifetime tobacco consumption, were compared on measures of learning and memory, response inhibition, information-processing, sustained attention, executive control, and mental and physical health.

RESULTS

Cannabis users exhibited poorer overall learning and delayed recall and greater interference and forgetting than tobacco users, and exhibited poorer recall than norms. Inhibition and executive control were similar between groups, but cannabis users had slower reaction times during information processing and sustained attention tasks. Cannabis users had superior health satisfaction and psychological, somatic, and general health than tobacco users and had similar mental and physical health to norms whilst tobacco users had greater stress, role limitations from emotional problems, and poorer health satisfaction.

CONCLUSIONS

Long-term cannabis users may exhibit deficits in some cognitive domains despite short-term abstinence and may therefore benefit from interventions to improve cognitive performance. Tobacco alone may contribute to adverse mental and physical health outcomes, which requires appropriate control in future studies.

Bone health and SATB2-associated syndrome

SATB2-associated syndrome (SAS) is a rare disorder caused by alterations in the special AT-rich sequence-binding protein 2 (SATB2). Skeletal abnormalities such as tibial bowing, osteomalacia, osteopenia or osteoporosis have been reported suggesting a higher frequency of skeletal complications in SAS. The optimal timing, necessity, and methodology for routine assessment of bone health in individuals with SAS, however, remain unclear. We report molecular and phenotypic features of 7 individuals with SAS documented to have low bone mineral density (BMD) ascertained by dual-energy X-ray absorptiometry (DXA), often preceded by tibial bowing. The lowest BMD Z-scores ranged -2.3 to -5.6. In 4 individuals, total alkaline phosphatase levels were elevated (2 with elevated bone fraction) around the time of low BMD documentation. A clinically significant fracture history and a diagnosis of pediatric osteoporosis were present in 4 individuals. Pamidronate treatment in 2 children improved BMD. In conclusion, low BMD, fractures, and tibial bowing are relatively common skeletal complications in individuals with SAS. DXA is a useful tool when evaluating a child with SAS suspected to have low BMD and the results might alter clinical management.

Transport and potential attenuation of nitrogen in shallow groundwaters in the lower Rangitikei catchment, New Zealand

Intensive agricultural activities are generally associated with nitrogen leaching from agricultural soils, and this nitrogen has the potential to percolate and contaminate groundwater and surface waters. We assessed surface water and groundwater interactions, and nitrogen leaching and its potential attenuation in shallow groundwater in the lower Rangitikei River catchment (832km²), New Zealand. We combined regional- and local-scale field surveys and experiments, nutrient budget modelling, and hydraulic and geochemical methods, to gain an insight into leaching, transformation and transport of nitrogen via groundwaters to the river in the study area. Concurrent river flow gaugings (in January 2015) and a piezometric map, developed from measured depths to groundwater in 110 bores (in October 2014), suggest groundwater discharges to the Rangitikei River in the upper parts of the study area, while there is groundwater recharge near the coast. The groundwater redox characterisation, based on sampling and analysis of 15 mostly shallow bores (<30m below ground level (bgl)), suggests groundwater across the lower Rangitikei catchment in general is under anoxic/reduced conditions. The groundwater typically has low dissolved oxygen (DO) concentrations (<1mg/L), suggesting the subsurface environment is conducive to potential attenuation by 'denitrification' of NO₃-N in groundwater. We further measured NO₃-N attenuation in shallow groundwater piezometers (3-6mbgl) using single-well push-pull tests. We found generally low levels (<0.5mg/L) of NO₃-N in shallow groundwater piezometers (>5mbgl), despite being installed under intensive land uses, such as dairying and cropping. Our in-field push-pull tests showed NO₃-N reduction at four shallow groundwater piezometers, with the rates of reduction varying from 0.04mgNL^-1h^-1 to 1.57mgNL^-1h^-1. This highlights the importance of a sound understanding of not only the sources, but also transport and transformation, or fate, of nutrients leached from farms, to mitigate the likely impacts of land use on water quality and ecosystem health in agricultural catchments.

Statin use and the risk of herpes zoster: a nested case-control study using primary care data from the U.K. Clinical Research Practice Datalink

Background

Statins are commonly prescribed worldwide and recent evidence suggests that they may increase the risk of herpes zoster (HZ).

Objectives

To quantify the effect of statin exposure on the risk of HZ in the U.K.

Methods

A matched case–control study was conducted using data from U.K. primary care and hospital records. Patients > 18 years with an incident diagnosis of HZ were matched to up to four controls for age, sex and general practice. Patients were included in the statin exposure group if they had ever used a statin, and the daily dosage of the most recent statin prescription and the time since the most recent statin prescription were also recorded. The primary outcome was an incident diagnosis of HZ. Odds ratios (ORs) were estimated from conditional logistic regression and adjusted for potential confounders.

Results

A total of 144 959 incident cases of HZ were matched to 549 336 controls. Adjusted analysis suggested strong evidence for an increase in the risk of HZ related to statin exposure (OR 1·13, 95% confidence interval 1·11–1·15). There was also an increased risk when dosages were increased for patients who were currently or had recently been receiving statin treatment (P_trend < 0·001), and we found an attenuation of the increased risk of HZ in previous statin users as the time since last statin exposure increased (P_trend < 0·001).

Conclusions

These findings are consistent with the hypothesis that statin therapy leads to an increase in the risk of HZ.

What's already known about this topic?

Studies in both Canada and Taiwan have recently reported a small but significantly increased risk of herpes zoster (HZ) in patients receiving statin treatment.

As statins are one of the most widely prescribed drugs in the U.K., with around 45 million prescriptions every year, any adverse effects will have substantial public health implications.

What does this study add?

In this large matched case–control study, statin exposure was associated with a modest increase in the risk of HZ.

A dose–response relationship was observed, and there was an attenuation of the increased risk over time among people who stopped statin therapy, indicating that the increased risk is consistent with a causal effect.

There may be extra motivation to maximize HZ vaccine uptake among eligible patients receiving a statin.

Linked Comment:Shalom and Cohen. Br J Dermatol 2016; 175:1137–1138.

Characteristics and in vitro response of thin hydroxyapatite-titania films produced by plasma electrolytic oxidation of Ti alloys in electrolytes with particle additions

Enhanced incorporation of hydroxyapatite nanoparticles in porous titania coating formed by plasma electrolytic oxidation significantly increases surface osteogenic activity.

The enhancement of the biological properties of Ti by surface doping with hydroxyapatite (HA) is of great significance, especially for orthodontic applications. This study addressed the effects of HA particle size in the electrolyte suspension on the characteristics and biological properties of thin titania-based coatings produced on Ti–6Al–4V alloy by plasma electrolytic oxidation (PEO). Detailed morphological investigation of the coatings formed by a single-stage PEO process with two-step control of the electrical parameters was performed using the Minkowski functionals approach. The surface chemistry was studied by glow discharge optical emission spectroscopy and Fourier transform infrared spectroscopy, whereas mechanical properties were evaluated using scratch tests. The biological assessment included in vitro evaluation of the coating bioactivity in simulated body fluid (SBF) as well as studies of spreading, proliferation and osteoblastic differentiation of MC3T3-E1 cells. The results demonstrated that both HA micro- and nanoparticles were successfully incorporated in the coatings but had different effects on their surface morphology and elemental distributions. The micro-particles formed an irregular surface morphology featuring interpenetrated networks of fine pores and coating material, whereas the nanoparticles penetrated deeper into the coating matrix which retained major morphological features of the porous TiO₂ coating. All coatings suffered cohesive failure in scratch tests, but no adhesive failure was observed; moreover doping with HA increased the coating scratch resistance. In vitro tests in SBF revealed enhanced bioactivity of both HA-doped PEO coatings; furthermore, the cell proliferation/morphometric tests showed their good biocompatibility. Fluorescence microscopy revealed a well-organised actin cytoskeleton and focal adhesions in MC3T3-E1 cells cultivated on these substrates. The cell alkaline phosphatase activity in the presence of ascorbic acid and β-glycerophosphate was significantly increased, especially in HA nanoparticle-doped coatings.

Strategies for engaging with future radiation protection professionals: a public outreach case study

It is evident that there is a nuclear skills shortage within the UK, and logically it can be assumed that the shortfall extends to the radiation protection arena. Plans for nuclear new-build and the decommissioning of existing nuclear sites will require many more people with radiological knowledge and practical competencies. This converts to a nuclear industry requirement in the order of 1000 new recruits per year over at least the next ten years, mainly as new apprentices and graduates. At the same time, the strong demand for persons with radiation protection know-how in the non-nuclear and health care sectors is unlikely to diminish. The task of filling this skills gap is a significant one and it will require a determined effort from many UK stakeholders. The Society for Radiological Protection (SRP) has adopted a strategy in recent years to help address this skills gap. The aim is to engage the interest of secondary school students in the science of radiation and inspire them to follow a career in radiation protection. This paper presents the reasoning behind this strategy and, in an 'outreach case study', describes the establishment of the annual SRP Schools Event. This event is becoming an important addition to the national efforts aimed at increasing the numbers of skilled UK radiation protection professionals over the forthcoming decades.

250 years of hybridization between two biennial herb species without speciation

Hybridization between plant species can generate novel morphological diversity and lead to speciation at homoploid or polyploid levels. Hybrids between biennial herbs Tragopogon pratensis and T. porrifolius have been studied in experimental and natural populations for over 250 years. Here we examine their current status in natural populations in southeast England. All hybrids found were diploid; they tended to grow taller and with more buds than their parental species; many showed partial fertility; a few showed evidence of backcrossing. However, we found no evidence to suggest that the hybrids are establishing as a new species, nor can we find literature documenting speciation of these hybrids elsewhere. This lack of speciation despite at least 250 years of hybridization contrasts with the fact that both parental species have formed new allopolyploid species through hybridization with another diploid, T. dubius. Understanding why hybrids often do not speciate, despite repeated opportunities, would enhance our understanding of both the evolutionary process and risk assessments of invasive species.

Making pathogens sociable: the [corrected] emergence of high relatedness through limited host invasibility

Cooperation depends upon high relatedness, the high genetic similarity of interacting partners relative to the wider population. For pathogenic bacteria, which show diverse cooperative traits, the population processes that determine relatedness are poorly understood. Here, we explore whether within-host dynamics can produce high relatedness in the insect pathogen Bacillus thuringiensis. We study the effects of host/pathogen interactions on relatedness via a model of host invasion and fit parameters to competition experiments with marked strains. We show that invasibility is a key parameter for determining relatedness and experimentally demonstrate the emergence of high relatedness from well-mixed inocula. We find that a single infection cycle results in a bottleneck with a similar level of relatedness to those previously reported in the field. The bottlenecks that are a product of widespread barriers to infection can therefore produce the population structure required for the evolution of cooperative virulence.

An Advanced Pharmacy Practice Framework for Australia

The need to develop An Advanced Pharmacy Practice Framework for Australia (the “APPF”) was identified during the 2010 review of the competency standards for Australian pharmacists. The Advanced Pharmacy Practice Framework Steering Committee, a collaborative profession-wide committee comprised of representatives of ten pharmacy organisations, examined and adapted existing advanced practice frameworks, all of which were found to have been based on the Competency Development and Evaluation Group (CoDEG) Advanced and Consultant Level Framework (the “CoDEG Framework”) from the United Kingdom. Its competency standards were also found to align well with the Domains of the National Competency Standards Framework for Pharmacists in Australia (the “National Framework”). Adaptation of the CoDEG Framework created an APPF that is complementary to the National Framework, sufficiently flexible to customise for recognising advanced practice in any area of professional practice and has been approved by the boards/councils of all participating organisations. The primary purpose of the APPF is to assist the development of the profession to meet the changing health care needs of the community. However, it is also a valuable tool for assuring members of the public of the competence of an advanced practice pharmacist and the quality and safety of the services they deliver.

Non-prescription treatment of NSAID induced GORD by Australian pharmacies: a national simulated patient study

BACKGROUND

Patients regularly present to community pharmacies for advice about and treatment for reflux symptoms and NSAIDs are a common cause of these symptoms. There is no published literature detailing the approach that pharmacies take to these enquiries, the pharmacotherapy they recommend or whether they contribute to the safe and effective use of reflux medicines.

OBJECTIVES

To assess in an observational study design the clinical history gathering, recommendations for GORD management and counselling provided by community pharmacies in a simulated patient scenario involving suspected NSAID induced reflux symptoms. Setting Australian community pharmacies.

METHOD

Simulated patients visited 223 community pharmacies to request treatment for reflux symptoms. The interaction was audiotaped and assessed against guidelines for the treatment of reflux symptoms.

MAIN OUTCOME MEASURES

Alignment of community pharmacies with international expert gastroenterologist guidance and national professional practice guidelines for the treatment of reflux symptoms by pharmacists including: consultation with a pharmacist; confirmation of reflux diagnosis based on symptoms; recommendation of short courses proton pump inhibitor (PPI) therapy; advice on the safe and effective use of reflux medicines and referral to a doctor for further assessment.

RESULTS

Pharmacists consulted with the simulated patient in 77% of cases. Symptoms were enquired about in 95% of cases and a medicines history taken in 69% of cases. Recommendations for treatment included: PPIs (18%), histamine H2 antagonists (57%) and antacids (19%). Advice on product use was given in 83% of cases. Referral to a doctor to discuss reflux symptoms was made in 63% of cases.

CONCLUSION

When assessing patients for the symptoms of GORD, Australian pharmacists and non-pharmacist support staff take a comprehensive history including symptomatology, duration of symptoms, concomitant medicines and medical conditions and any GORD treatments previously trialled. They provide comprehensive counselling on the use of antisecretory and antacid medicines. Counselling could involve more comprehensive information on lifestyle approaches for GORD management and side effects of antisecretory and antacid medicines. Further alignment with guidelines for the management of GORD would result in greater referral to a doctor for assessment of recurrent GORD and greater recommendation of PPIs for symptoms. However alignment with guidelines by all pharmacists is unrealistic if the guidelines are not universally available to them.

Bacterial Cooperation Causes Systematic Errors in Pathogen Risk Assessment due to the Failure of the Independent Action Hypothesis

The Independent Action Hypothesis (IAH) states that pathogenic individuals (cells, spores, virus particles etc.) behave independently of each other, so that each has an independent probability of causing systemic infection or death. The IAH is not just of basic scientific interest; it forms the basis of our current estimates of infectious disease risk in humans. Despite the important role of the IAH in managing disease interventions for food and water-borne pathogens, experimental support for the IAH in bacterial pathogens is indirect at best. Moreover since the IAH was first proposed, cooperative behaviors have been discovered in a wide range of microorganisms, including many pathogens. A fundamental principle of cooperation is that the fitness of individuals is affected by the presence and behaviors of others, which is contrary to the assumption of independent action. In this paper, we test the IAH in Bacillus thuringiensis (B.t), a widely occurring insect pathogen that releases toxins that benefit others in the inoculum, infecting the diamondback moth, Plutella xylostella. By experimentally separating B.t. spores from their toxins, we demonstrate that the IAH fails because there is an interaction between toxin and spore effects on mortality, where the toxin effect is synergistic and cannot be accommodated by independence assumptions. Finally, we show that applying recommended IAH dose-response models to high dose data leads to systematic overestimation of mortality risks at low doses, due to the presence of synergistic pathogen interactions. Our results show that cooperative secretions can easily invalidate the IAH, and that such mechanistic details should be incorporated into pathogen risk analysis.

Australian pharmacies prevent potential adverse reactions in patients taking warfarin requesting over-the-counter analgesia

Objective

The objective of this article was to assess if Australian pharmacy staff prevent potential adverse reactions in warfarin patients requesting over-the-counter (OTC) analgesia.

Methods

Mystery shoppers entered 170 pharmacies across Australia to request OTC analgesia for a hypothetical patient with a wrist injury who currently takes warfarin following a heart valve replacement. The request was made to the first pharmacist or non-pharmacist staff member to approach the mystery shopper. The interaction was audio-taped and assessed by a pharmacist. The OTC analgesic recommended was assessed for the potential to cause an adverse bleeding event. The quality of advice given with the OTC analgesic was assessed against determined criteria. Results were compared with scenarios of similar request type where the hypothetical patient was not taking warfarin.

Key findings

Mystery shoppers enquiring about taking OTC analgesics concomitantly with warfarin had access to the pharmacist in 97.0% of cases. All 170 pharmacies recommended OTC analgesics that were less likely to cause adverse events when taken with warfarin. The advice given and the communication between pharmacy staff and mystery shoppers were of high quality.

Conclusion

Australian pharmacies support the quality use of medicines by patients taking warfarin by providing expeditious access to the pharmacist, appropriate recommendations of OTC analgesics, high standards of quality of advice and they communicate in a way to ensure ease of understanding by the consumer. The protocols used by pharmacy staff help prevent potentially serious adverse drug events.